Sunset Drive - a Prospera Community

Based on observations, review of facility policy, review of facility assessment, review of call light logs, and confidential staff interview, the facility failed to provide sufficient nursing staff and related services necessary to meet the needs for 5 of 7 sampled residents (Resident #3, #4, #5, #6, and #7) who required staff assistance. Failure to provide sufficient nursing staff may result in residents experiencing unmet needs, poor hygiene, incontinence, and skin issues and may negatively affect the residents' mental, physical and psychosocial well-being.Findings include:Review of the facility policy titled Nursing Services Staff occurred on 07/28/25. This policy, dated October 2024, stated, . The facility must have sufficient nursing staff . to ensure resident safety and attain or maintain the highest practicable, physical, mental, and psychosocial well-being of each resident .Review of the Facility Assessment occurred on 07/28/25. The assessment stated, . Staffing needs are met by providing adequate staff to each of the units and monitored by Nursing Administration and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, review of professional reference, and staff interview, the facility failed to follow professional standards of practice for timely medication administration for 7 of 7 sampled residents (Resident #1, # 2, #3, #4, #5, #6, and #7). Failure to administer medications in a timely manner may cause adverse effects for the residents. Findings include:The facility failed to provide a policy regarding timely medication administration.Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 834-835, stated, . administer the medication . at the correct time. Table 35.8 . Process of Administering Medications. NON-TIME-CRITICAL MEDICATIONS . Medications prescribed . within 1 hour before or after the scheduled time. - Review of Resident #1's medication administration record (MAR), dated May 2025 showed staff administered medications over one hour late on ten occasions.- Review of Resident #2's MAR dated May 2025 showed staff administered medications over one hour late on seven occasions.- Review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility policy, and staff interview, the facility failed to ensure the code level status accurately reflected the resident's wishes for 5 of 27 sampled residents (Resident #19, #80, #108, #111, and #119) reviewed for advance directives. Failure to ensure the medical record and other forms of communication accurately reflected the resident's code status limited the facility's ability to communicate to direct care staff and emergency personnel the resident's choice in the event of a medical emergency. Findings include: Review of the facility policy titled Advance Directive including Cardiopulmonary Resuscitation (CPR) and Automated External Defibrillator (AED) occurred on [DATE]. This policy, dated, [DATE], stated, . To define a process to make resident decisions known. Residents have the right to formulate advance directives. Review of Resident #19's medical record occurred on all days of survey and identified palliative care (comfort care). Physician's orders, dated [DATE],…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, review of facility policy, and staff interview, the facility failed to ensure a safe, clean, comfortable, and homelike environment for 4 of 27 sampled residents (Resident #14, #67, #69, and #99) and 2 supplemental residents (Resident #70 and #284). Failure to maintain a safe, clean, and sanitary environment may lead to injury from unsafe equipment, does not provide a homelike living area for residents, and does not promote quality of life. Findings include: Review of the facility policy titled Preventative Maintenance-Affordable Housing occurred on 05/15/25. This policy, dated November 2024, stated, . provide a safe environment for our residents . a preventative maintenance program will be implemented to promote the maintenance of buildings and equipment in a state of good repair and condition and free from safety hazards. - Observations on 05/12/25 identified the following: *10:20 a.m., A strong urine odor in Resident # 99's room. *11:50 a.m., Resident #284's bed stripped of all linens. *10:22 a.m., A strong urine odor and a sticky bathroom floor in Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, review of facility policy, and staff interview, the facility failed to review and revise care plans to reflect the residents' current status for 6 of 27 sampled residents (Resident #2, #27, #55, #66, #67, and #119) and 1 supplemental resident (#59). Failure to update care plans limited the staff's ability to communicate needs and ensure continuity of care. Findings include: Review of the facility policy titled Care Plan-R/S, LTC, Therapy & Rehab occurred on 05/15/25. This policy, dated December 2024, stated, Each resident will have an individualized, person-centered, comprehensive plan of care . The care plan will emphasize the care and development of the whole person ensuring that the resident will receive appropriate care and services. - Review of Residents #2, #27, #55, #59, #66, #67, and #119 medical records occurred on all days of survey and identified diagnoses of diabetes, and physician's orders for insulin. These residents' care plans lacked signs and symptoms of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) to be monitored and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and resident and staff interview, the facility failed to ensure residents received the necessary services to maintain personal hygiene for 4 of 27 sampled residents (Resident #2, #29, #55, and #76) and 2 supplemental residents (Resident #88 and #120) who required staff assistance for bathing. Failure to aid residents who cannot perform the bathing and nail care task independently may result in poor hygiene, skin related issues, and decreased self-esteem. Findings include: The facility failed to provide a policy. - Random observations of Resident #2 on all days of survey showed Resident #2's fingernails extended approximately one fourth inch beyond the finger with dark debris under the nails. Review of Resident #2's medical record occurred on all days of survey. The current care plan stated, . The resident has an ADL [activities of daily living] self care performance deficit . BATHING: Resident requires assist x 1 [times one staff] will receive a minimum of one bed bath/shower/bath per week . PERSONAL HYGIENE: Resident requires assist x 2 [times…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of resident council meeting minutes, confidential resident interviews, and staff interviews, the facility failed to ensure sufficient nursing staff and related services are available at all times to meet the residents' needs for 7 of 27 confidential residents (Resident A, B, E, H, I, J, and K) who required staff assistance. Failure to provide sufficient staffing does not promote each resident's rights, physical, mental, and psychosocial well-being, and/or provide a safe environment for the residents. Findings include: Review of the Resident Council meeting minutes, dated 01/13/25 through 04/24/25 identified the following: * 02/23/25, . Staff turning off call lights without meeting the residents needs continue to be addressed as well as call light times. * 02/27/25, . There were several complaints about CNAs [certified nurse aides] turning off lights and not coming back. Residents feel that the call light times are lengthy nursing will look into this issue and report back. * 03/31/25, . There were several complaints about CNAs turning off lights and not coming back.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility policy, review of resident council meeting minutes, and resident and staff interviews, the facility failed to serve foods at palatable temperatures in 4 of 4 units (Sunset, Edgewater, Grandview, and [NAME]). Failure to serve foods at a temperature acceptable to residents may result in decreased intake, weight loss, and inadequate nutrition. Findings include: Review of the facility policy titled Food Temperature Monitoring - Food and Nutrition Services occurred on 05/15/25. This policy, revised 12/16/24, stated, . Proper serving temperature - a temperature that is . appetizing to the resident . this is the temperature when the food reaches the resident. Test tray monitoring occurs as part of quality assurance monitoring to ensure temperatures are acceptable when the location uses room trays or satellite dining rooms. Test tray is checked after all residents have been served. Confidential resident interviews conducted during the survey identified the following: * Resident A…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 9 of 10 sampled residents (Resident #2, #3, #6, #19, #26, #29, #67, #107, and #281) observed during cares. Failure to practice infection control standards related to enhanced barrier precautions (EBP), catheter care, dressing changes, glove use, hand hygiene, and disinfecting of shared equipment has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Catheter: Care, Insertion & [and] Removal, Drainage Bags, Irrigation, Specimen occurred on 05/15/25. This policy, revised 04/05/25, stated, . Connecting Leg Bag. Following insertion of an indwelling urinary catheter, it is recommended to maintain a closed urinary drainage system. 4. Swab attachment site of catheter with alcohol pad. 5. clamp catheter. 6. After wiping cap with alcohol pad, disconnect catheter and drainage tubing and do not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to complete an assessment and obtain a physician's order for self-administration of medications for 1 of 1 sampled resident (Resident #108) observed with medications at the bedside. Failure to evaluate the resident's ability to safely self-administer medications may result in medication errors and/or harm to the resident. Findings include: Review of the facility policy titled Resident Self-Administration of Medication occurred on 05/15/25. This policy, revised 10/29/24, stated, . Complete the Resident Self-Administration of Medications UDA [user defined assessment] to determine if the resident can safely administer medications . A physician's order must be obtained prior to the resident self-administering medications. Review of Resident #108's medical record occurred on all days of survey. The record lacked a facility assessment and physician's order for self-administration of medications. Observation on 05/12/25 at 10:52 a.m. identified two paper medication cups, one cup held…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review, and staff interview, the facility failed to promote care in a manner that maintained or enhanced residents' dignity for 1 of 27 sampled residents (Resident #2) and 1 supplemental resident (Resident #32) who required assistance with personal hygiene. Failure to ensure the residents face and positioning devices are clean, and doors are closed during toileting does not promote the resident's mental well-being or dignity. Findings include: - Review of Resident #2's medical record occurred on all days of survey. The current care plan identified assistance required for dressing, repositioning, and personal hygiene. Observations of Resident #2 showed the following: * 05/12/25 at 11:21 a.m., seated in a wheelchair in the day room and a chest vest positioning device soiled with debris. * 05/13/25 at 8:04 a.m., seated in a wheelchair at the dining table and a chest vest positioning device soiled with debris. * 05/14/25 at 7:44 a.m., seated in a wheelchair at the dining table with head down, a chest vest positioning device in place soiled with debris. *…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, review of facility policy, and resident interview, the facility failed to ensure reasonable accommodation of needs regarding call lights for 1 of 1 sampled resident (Resident #2). Failure to place call lights within reach may result in an inability to call for help, discomfort, increased falls, and/or incontinence.Findings include:Review of the facility policy titled Call Light occurred on 07/09/25. This policy, dated 07/29/24, stated, PURPOSE: To ensure resident always has a method of calling for assistance . PROCEDURE . When leaving the room, place call light within easy reach of resident. Review of Resident #2's medical record occurred on all days of survey. The care plan stated, . Resident is legally blind, describe location of items at bedside. non-ambulatory . Observations on 07/07/25 at 11:37 a.m. and 07/08/25 at 11:15 a.m. showed Resident #2 in bed and the call light placed on a chair located at the foot of the bed. When asked about the call light, Resident #2 stated, Every time they [facility staff] work with me, they move it there [the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, review of facility policy, and staff interview, the facility failed to provide a written notice of room change for 1 of 1 sampled resident (Resident #1) reviewed with a recent room change. Failure to provide the resident and/or resident's representative a written explanation of why a move is required prevents the resident and/or representative from making informed decisions significant to the resident's care. Findings include: Review of the facility policy titled Room/Roommate Change occurred on 07/09/25. This policy, dated 12/12/24, stated, . The resident has the right to receive written notice, including the reason for the change, before the resident's room . location is changed. Social services or a designated employee will discuss any proposed change in room with the resident and/or resident representative. The resident and/or representative must be given a reason for the move and provided the opportunity to see the new location and ask questions about the move. Review of Resident #1's medical record occurred on all days of survey and identified a room…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, review of facility policy, and resident and staff interview, the facility failed to honor resident choices for 2 of 2 sampled residents (Resident #55 and #99) who had personal food items stored in the resident fridge. Failure to honor the resident's choice of personal food items at meals or when requested does not respect their autonomy or right to determine what is significant to their care and well-being. Findings include: Review of the facility policy titled, Safe Food Handling of Personal Food, Outside Food-Food and Nutrition occurred on 05/16/25. This policy, dated 05/13/24, stated, . Employees assist residents in accessing and consuming personal food if the resident is unable to do so on his or her own. Personal food is stored separate from the location's food. Review of a document in the facility admission packet titled Outside Food, occurred on 05/14/25. This undated document stated, Personal fridges are not allowed in individual rooms. Refrigerated food in small amounts can be stored in resident fridge in the main kitchen. All perishable…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of a facility reported incident (FRI), review of facility investigative reports, and staff interview, the facility failed to ensure residents remained free from abuse for 2 of 2 sampled residents (Resident #47 and #76) with impaired cognition who displayed sexual behaviors towards other residents. Failure to protect residents from sexual abuse may result in fear, anxiety, mental anguish, and physical injury. Findings include: Review of the facility policy titled Abuse and Neglect occurred on 05/15/25. This policy, dated 07/22/24, stated, . PURPOSE: To ensure . an effective system in place that . prevents mistreatment, neglect, exploitation and abuse of resident . The resident has the right to be free from abuse, neglect . and exploitation. Residents must not be subjected to abuse by anyone, including . other residents . Review of a FRI, dated 03/03/25, indicated a medication aide (MA) prepared medications near the dining room and observed Residents #47 and #76 seated at opposite…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and review of facility policy, the facility failed to report incidents of potential abuse to the State Survey Agency (SSA) for 2 of 2 sampled residents (Resident #47 and #76) who displayed sexual behaviors towards other residents. Failure to report events of potential sexual abuse to the SSA placed Resident's #47 and #76 and all other residents at risk for possible abuse, mental and emotional distress, and/or physical injury. Findings include: Review of the facility policy titled Abuse and Neglect occurred on 05/15/25. This policy, dated 07/22/24, stated, . Residents must not be subjected to abuse by anyone, including . other residents . Results of all investigations will be reported . to the state survey and certification agency within five working days of the incident, or sooner as designated by state law . - Review of Resident #47' medical record occurred on all days of survey. A progress note, dated 04/23/25 at 9:20 a.m., stated . [Resident #47] and I discussed an incident that was reported the night of 4/20 [2025]. When asked if the incident happened,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and review of facility policy, the facility failed to provide the resident or their representative and the State Long Term Care Ombudsman a written notice of transfer and bed-hold notice for 1 of 5 sampled residents (Resident #37) reviewed for hospitalizations. Failure to provide a notice of transfer and a bed-hold notice does not allow the resident and/or their representative to make informed decisions regarding their rights, or inform the Ombudsman of the transfer. Findings include: Review of the facility policy titled Discharge And Transfer occurred on 05/15/25. This policy, dated 03/28/25, stated, . Before a location transfers . the location must: 1. Notify the resident and the resident's representative of the transfer . in writing . the location must send a copy . to a representative of the Office of the State Long-Term Care Ombudsman . Review of the facility policy titled Bed-Hold occurred on 05/15/25. This policy, dated 12/19/24, stated, . PURPOSE: To ensure that the resident/resident representative is made aware of the facility's bed hold and reserve…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, and review of the federal database for Long-Term Care Survey, the facility failed to ensure timely electronic data submission of required Minimum Data Set (MDS) assessments for 1 of 27 sampled residents (Resident #281). Failure to follow the MDS data submission specifications does not meet the intended regulatory requirements. Findings include: The Long-Term Care Facility RAI 3.0 User's Manual (Version 1.19), page 2-33 and 2-34, stated, Non-Comprehensive assessments and Entry and Discharge Reporting Discharge Assessment - Return Anticipated . The MDS must be transmitted . electronically no later than 14 calendar days after the MDS completion date . Page 2-38 stated, Entry Tracking Records . Must be submitted no later than the 14th calendar day after the entry . Page 5-1 stated, . All Medicare and/or Medicaid-certified nursing homes . must transmit required MDS data records to CMS'…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

1. Based on observation, review of facility policy, and staff interview, the facility failed to ensure staff followed standards of practice for 1 of 1 supplemental resident (Resident #284) observed during insulin preparation. Failure to properly prime insulin pens may result in the resident receiving an inaccurate dose of insulin. Findings include: Review of the facility policy titled Medication: Insulin Administration, Insulin Pens, Insulin Pumps occurred on 05/14/25. This policy, dated 09/05/24, stated, . Insulin Pen: . Turn the dosage knob to '2' units to prime the pen. Observation on 05/13/25 at 12:16 p.m. showed a facility nurse (#10) prepare an insulin pen for Resident #284. After placing a new cap on the pen, the nurse (#10) dialed the insulin pen to the prescribed dose without priming the pen. When asked if she had primed the pen, the facility nurse (#10) stated she never primes an insulin pen. During an interview on 05/13/24 at 12:20 p.m., an administrative nurse (#2) confirmed staff should prime insulin pens before dialing to the prescribed insulin dose. 2. Based on record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility policy, and resident and staff interviews, the facility failed to provide an ongoing program of meaningful activities designed to meet the interests and preferences for 1 of 27 sampled residents (Resident #76) and 1 confidential resident (Resident I). Failure to provide meaningful activities for residents limits their ability to reach their highest practicable level of physical, mental, and psychosocial well-being. Findings include: Review of the facility policy titled Activity Services Calendar occurred on 05/15/25. This policy, dated 12/30/24, stated, . The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities . to meet the interests of and support the physical, mental, and psychosocial well-being of each resident . The activity services calendar of events will be based on resident interests and abilities as well as the care plan goals and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interviews, the facility failed to ensure 1 of 2 sampled residents (Resident #6) reviewed for limited range of motion received restorative services as per care plan. Failure to consistently provide restorative nursing/therapy services may adversely affect the resident's ability to maintain their range of motion (ROM). Findings include: Review of Resident #6's medical record occurred on all days of survey. Diagnosis included Parkinsons's disease and abnormal posture. A quarterly Minimum Data Set (MDS), dated [DATE], identified impairment to upper and lower extremities (arms and legs) bilaterally. The current care plan stated, . Resident has a need for restorative intervention R/T [related to] contractures from Parkinsons. Arm and leg exercises both sides. Range of motion [ROM] exercises provided weekly or bath/shower days as available. Stuffed animal to be placed in hands for contractures. Observation of Resident #6 occurred on all days of survey and identified the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, review of facility policy, and resident interview, the facility failed develop an effective pain management regimen and schedule routine pain medications to meet residents' needs for 1 of 3 sampled residents (Resident #67) reviewed for pain management. Failure to develop and implement an acceptable and manageable pain management plan resulted in unresolved pain and discomfort. Findings include: Review of the facility policy titled Pain Management occurred on 05/15/25. This policy, dated 01/31/25, stated, . The licensed nurse will review response to medication intervention and work closely with the physician to assist in the individualized pain management plan. The nurses working directly with residents must continually monitor and observe the resident for success of the pain management plan and report to the nurse manager and prescriber as necessary to keep the resident comfortable. a pain management plan should be person centered . The interdisciplinary team and nurses must…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, review of facility policy, and staff interview, the facility failed to ensure residents remained free from significant medication errors for 1 of 1 sampled resident (Resident #67) with a medication not held prior to scheduled surgery. Failure to accurately transcribe and follow physician's orders may result in adverse health consequences and/or delayed treatment for the resident. Findings include: Review of the facility policy titled Medication Errors occurred on 05/15/25. This policy, dated 04/08/25, stated, Definitions . Significant Medication Error: One which causes the resident discomfort or jeopardizes his or her health and safety . Medication Error Types . Transcription Error: Inaccurate transcription of an order. Review of Resident #67's medical record occurred on all days of survey. A physician's order, dated 05/09/25, stated, preop [preoperative {before surgery}] instructions for surgery on 5/16/25. hold . ASA [aspirin] . 5 days before surgery. Review of Resident #67's May 2025 medication administration record (MAR) identified the facility failed to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, review of facility policy, and staff interview, the facility failed to store and serve food properly in 1 of 4 units (Grandview) observed during/after meal service. Failure to ensure food is stored at proper temperatures and served in a sanitary manner may result in foodborne illness to residents, staff, and visitors. Findings include: Review of the facility policy titled Food Temperature Monitoring occurred on 05/14/25. This policy, dated 12/16/24, stated, . Proper holding temperature - Temperature required for food safety (cold food < [less than] 41 degrees Fahrenheit [F].) - Observation on 05/14/25 at 3:09 p.m. in the Grandview Unit Kitchenette showed the following items in a cold well (open refrigerated area built into the counter) * A half gallon of milk measured 46.8 degrees F * A side salad containing lettuce, egg, and tomato * Containers of grape, cranberry and prune juice. The cranberry juice measured 46.8 degrees F. The cold well had approximately one half inch of frost build up on all four of the inner sides. A facility refrigerator thermometer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility policy, and resident and staff interviews, the facility failed to ensure residents remained free from abuse from 2 of 2 sampled residents (Resident #1 and #2) who displayed sexual behaviors towards other residents. Failure to protect residents from sexual abuse may result in fear, anxiety, mental anguish, and physical injury. Findings include: Review of the facility policy titled Abuse and Neglect - Rehab/Skilled occurred on 01/08/25. This policy, revised 07/22/24, stated, . Purpose . To ensure that residents are not subjected to abuse by anyone, including, but not limited to . other residents . To ensure that all identified incidents of alleged or suspected abuse/neglect . are promptly reported and investigated. -Review of Resident #1's medical record occurred on 01/08/25. Diagnoses included dementia. An admission Minimum Data Set (MDS), dated [DATE], identified mild cognitive impairment. The care plan, dated 01/05/25, stated, The resident has a behavior symptom R/T…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility policy, and staff interview, the facility failed to report incidents of resident-to-resident abuse to the administrator and State Survey Agency (SSA) for 2 of 2 sampled residents (Resident #1 and #2) who exhibited sexual behaviors. Failure to report incidents of sexual abuse may result in unwanted physical and/or sexual contact and may cause all residents to experience fear, anxiety, and psychosocial harm. Findings include: Review of the facility policy titled Abuse and Neglect - Rehab/Skilled occurred on 01/08/25. This policy, revised 07/22/24, stated, . Purpose . To ensure that residents are not subjected to abuse by anyone, including, but not limited to . other residents . To ensure that all identified incidents of alleged or suspected abuse/neglect . are promptly reported and investigated. -Review of Resident #1's medical record occurred on 01/08/25. Diagnoses included dementia. An admission MDS (Minimum Data Set), dated 11/05/24, identified mild cognitive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility policy, and staff interview, the facility failed to notify the resident's physician of a change in condition for 1 of 2 closed record residents (Resident #6) reviewed. Failure to notify the physician of increased abdominal pain, tenderness, rigidity, and vomiting may have prevented the physician from altering the treatment/care provided to the resident. Findings include: Review of the facility policy titled Notification of Change occurred on November 5, 2024. This policy, dated 12/04/23, stated, . A facility must immediately inform the resident, consult with the resident's physician and notify, consistent with his or her authority, the resident representative(s) when there is: . 2. A significant change in the resident's physical, mental or psychosocial status. 3. A need to alter treatment significantly - a need to discontinue or change an existing form of treatment or to commence a new form of treatment. Review of Resident #6's medical record occurred on November 5,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 1 of 1 sampled residents (Resident #2) with an indwelling suprapubic catheter observed during cares. Failure to practice infection control standards related to enhanced barrier precautions has the potential to spread infection throughout the facility. Findings include: Review of the facility's policy titled Standard and Transmission Based Precautions, All Service Lines occurred on 10/02/24. This policy, revised 04/02/24, stated, Enhanced Barrier Precautions (EBP) . Enhanced barrier precautions expand the use of PPE (personal protective equipment) beyond situations in which exposure to blood and body fluids is anticipated and refer to use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug-resistant organisms [MRDOs] to staff hands and clothing. Enhanced barrier precautions are needed for residents with . Indwelling Medical devices (central lines,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, review of facility policy, and resident interview, the facility failed to ensure reasonable accommodation of needs regarding call lights for 5 of 10 sampled residents (Residents #2, #3, #4, #5, #6). Failure to place call lights within a resident's reach may result in an inability to call for help, increased falls, discomfort and/or incontinence. Findings include: Review of the facility policy titled Call Lights occurred on 07/31/24. This policy, dated 07/29/24, stated, . PURPOSE To ensure resident always has a method of calling for assistance . PROCEDURE . When leaving the room, place call light within easy reach of the resident. Random observations on 07/30/24 showed the following: * At 3:25 p.m. and 6:15 p.m., Resident #3 rested in bed with the call light located on the overbed table and out of reach. * At 3:25 p.m., Resident #4 asleep in bed. The call light hung from the bottom rung of the bed rail and out of reach. * At 3:26 p.m. and 6:16 p.m., Resident #5 asleep in bed with the call light located on the bedside table out of reach. * At 3:26 p.m. and 6:18…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, review of the North Dakota Long Term Care Ombudsman Program Guide to Resident Rights, and resident interview, the facility failed to provide care for 2 of 10 sampled residents (Resident #1 and #2) in a manner that promotes, maintains, or enhances their quality of life. Failure to cover a urinary catheter bag (Resident #1) and failure to provide care in a dignified manner (Resident #2) does not preserve the resident's personal dignity and/or enhance their quality of life and has the potential to affect the resident's psychosocial well-being. Findings include: The North Dakota Long Term Care Ombudsman Program's Guide to Resident Rights, updated 03/21/23, page 16, stated, . The facility must treat you courteously, fairly and with dignity. - Review of Resident #2's medical record occurred on all days of survey and identified assistance of one to two staff for toileting and total assistance with dressing. Observation on 07/30/24 at 3:59 p.m. showed a certified nurse aide (CNA) (#4) entered Resident #2's room to provide incontinence cares. The CNA removed the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, professional reference review, resident interview, and staff interview, the facility failed to provide appropriate toileting for 1 of 4 sampled residents (Resident #2) observed for toileting. Failure to provide toileting assistance as care planned may result in a loss of dignity and placed the resident at risk for skin breakdown, poor grooming/hygiene, decreased self-esteem, and urinary tract infections. Findings include: Kozier & Erb's Fundamentals of Nursing: Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 892, stated, Fecal and Urinary Incontinence: Moisture from incontinence promotes skin maceration [tissue softened by prolonged wetting or soaking] and makes the epidermis [skin] more easily eroded and susceptible to injury. Page 1221 stated, . scheduled toileting, attempts to keep clients dry by having them void at regular intervals, such as every 2 to 4 hours. The goal is to keep the client dry . Review of Resident #2's medical record occurred on all days of survey. The care plan stated, .…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, review of facility policy, review of the facility call light logs, resident interview, and staff interview, the facility failed to promptly respond to residents' call lights for 2 of 2 sampled residents (Resident #1 and #8) observed with prolonged call light wait times. Failure to promptly respond to calls for assistance may result in falls and residents experiencing unmet needs and may negatively affect the residents' physical, mental, and psychosocial well-being. Findings include: Review of the facility policy titled Call Light occurred on 07/31/24. This policy, dated 07/29/24, stated, . PURPOSE . To promptly answer resident's call light. PROCEDURE . When resident's call light is observed/heard, go to resident's room promptly. Respond to request as soon as possible. Turn call light off and inquire about resident's request. - Review of Resident #8's medical record occurred on all days of survey. The care plan stated, . The resident has an ADL [activities of daily living] self care performance deficit R/T [related to] deconditioning E/B [evidenced by]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control for 3 of 3 sampled residents (Resident #2, #9, and #10) observed receiving toileting assistance. Failure to follow infection control practices regarding hand hygiene during cares has the potential for transmission of communicable diseases and infections to residents, staff, and visitors. Findings include: Review of the facility policy titled Hand Hygiene occurred on 07/31/24. This policy, dated 03/29/22, stated, . All employees in patient care areas . will adhere to the 4 Moments of Hand Hygiene. 1. Entering room [ROOM NUMBER]. Before Clean Task 3. After Bodily Fluid/Glove Removal 4. Exiting Room . Hand hygiene should be performed after glove removal. Observations on 07/30/24 showed the following: * At 4:15 p.m., two certified nurse aides (CNAs) (#3 and #4) provided toileting cares to Resident #2 while in bed. Both CNAs donned gloves and removed the resident's soiled brief. The one…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of a facility reported incident (FRI), review of facility policy, and staff interview, the facility failed to ensure a resident's right to be free of physical restraints imposed for purposes of convenience for 1 of 2 sampled residents (Resident #1) reviewed for restraints. Failure to use a restraint only if required to treat a resident's medical symptoms placed Resident #1 at risk for an unnecessary restraint and injury. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately after learning of the incident. Findings include: Review of the facility policy titled Restraints occurred on 06/19/24. This policy, dated 12/05/23, stated, . Policy: Residents are free from any physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms. Physical Restraints - Any . material or equipment attached or adjacent to the resident's body that the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, review of facility policies, review of professional reference, and staff interview, the facility failed to ensure food is prepared and stored in a clean and sanitary manner in 1 of 1 kitchen and 1 of 4 kitchenettes (Unit 2). Failure to ensure cleanliness of food preparation and storage areas has the potential to result in a foodborne illness to residents, visitors, and staff. Findings include: Review of the policy titled, Food -Supply Storage occurred on 05/02/24. This policy, dated 05/11/23, stated, . Procedure. 9. Use By. dates are checked on a regular basis; foods/fluids that have expired. for use are discarded. Review of the policy titled, Date Marking occurred on 05/02/24. This policy, dated 04/03/24, stated, . Procedure. 1. b. Observe for USE by date or USE or FREEZE by date. This is an expiration date. d. If the items are removed from the original container/package, individual items are labeled and dated with date. 2. a. Ensure that. foods opened. are clearly date-marked for: 1) The date/time the original container is opened. 3. a.Foods prepared. and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 05/11/23. Based on observation, record review, facility policy review, and staff interview, the facility failed to follow standards of infection control for 7 of 26 sampled residents (Resident #7, #23, #40, #58, #73, #80, and #83) observed during cares. Failure to follow infection control standards with use of personal protective equipment (PPE), during toileting, and colostomy care has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Personal Protective Equipment PPE including Putting on/Taking off, All Service Lines - Enterprise occurred on 05/02/24. This policy, revised 12/04/23, stated, Sequence for donning and Removing Personal Protective Equipment - CDC [Centers for Disease Control and Prevention]. The type of PPE used will vary based on the level of precautions required, such as standard and contact, droplet or airborne infection isolation precautions.1. Gown. Fasten in back of neck and waist. 2. Mask or Respirator [N95 mask]. Secure ties. Fit flexable…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, review of facility policy, and staff interview, the facility failed to notify the physician of a change in condition for 1 of 1 sampled resident (Resident #67) reviewed who experienced low blood sugars. Failure to notify the physician of blood sugar results below the ordered parameters may result in complications to the resident and prevent the physician from evaluating/prescribing an appropriate treatment plan. Findings include: Review of the facility policy titled Notification of Change occurred on 05/02/24. This policy, revised 12/04/23, stated, . A facility must immediately . consult with the resident's physician . when there is . A significant change in the resident's physical . status . Review of Resident #67's medical record occurred on all days of survey. Diagnoses included type 2 diabetes. Medications included, . NovoLOG [Insulin] . Inject as per sliding scale: if 0 - 60 = call [sic] provider . The current care plan stated, . MEDICATIONS AND BLOOD SUGAR MONITORING PER ORDER TIMING AND DOSING MAY VERY DUE TO RESIDENT BRITTLE DIABETIC STATUS NOTFIY…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to assess the use of a wheelchair lap belt as a possible restraint for 1 of 4 sampled residents (Resident #52) observed with a wheelchair lap belt. Failure to assess the wheelchair lap belt as a possible restraint, monitor the use, and evaluate the need for continued use, placed Resident #52 at risk for an unnecessary restraint and injury related to its use. Findings include: Review of the facility policy titled Restraints occurred on 05/02/24. This policy, revised 12/05/23, stated, . Anytime a device, material or equipment is attached or placed adjacent to the resident's body, a determination will be made by a licensed nurse as to whether it is or could be a restraint . and a Physical Device and/or Restraint Evaluation and review is completed. There will be documentation in the medical record of the resident's response to . and ongoing re-evaluation of the need for the restraint. Observation on 04/30/24 at 11:15 a.m., showed Resident #52 seated in a wheelchair with a lap belt in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.18.11), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 3 of 25 sampled residents (Resident #12, #25, and #40). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: The Long-Term Care Facility RAI Manual, revised October 2023, page N-7, stated, . N0415: High-Risk Drug Classes: Use and Indication (cont.) . N0415D 1. Hypnotic: Check if a hypnotic medication was taken by the resident at any time during the 7-day look-back period . - Review of Resident #12's medical record occurred on all days of survey. The quarterly MDS, dated [DATE], showed Item N0415D coded as the resident received a hypnotic medication within the 7-day look back period. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

1. Based on observation, record review, review of professional reference, and staff interview, the facility failed to follow professional standards for 1 of 1 sampled resident (Resident #316) with intravenous (IV) administrations. Failure of staff to label, date, and time the IV solution bags may result in medication errors and adverse reactions. Findings include: Review of the facility's policy titled Medication: Intravenous Administration occurred on 05/02/24. This policy, dated 03/29/24, stated, . All IV solution containers will be labeled with the resident's name . time of preparation . Review of Resident #316's medical record occurred on all days of survey. A current physician's order stated, Administer LR [lactated ringers] 100 cc [cubic centimeters]/hr [hour] for 10 hours daily (Total: 1000 cc per 24 hrs [hours]). Observation from 04/29/24 to 04/30/24 showed an IV solution bag of lactated ringer's (an electrolyte solution) not labeled with the resident's name, date, and time. During an interview on 05/02/24 at 2:45 p.m., an administrative nurse (#1) confirmed staff did not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

1. Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide care and services for 1 of 1 sampled resident (Resident #417) observed during a PICC [peripherally inserted central catheter] line dressing change. Failure to follow physician's orders regarding dressing changes may result in delayed treatment and the resident experiencing adverse consequences. Findings include: Review of the facility policy titled Peripherally Inserted Central Catheter Line occurred on 05/02/24. This policy, revised 04/01/24, stated, . PROCEDURE: assess the catheter insertion site through the transparent semi-permeable dressing . assess for redness, swelling, drainage . DRESSING CHANGE: REMOVE THE OLD DRESSING . assess the site and skin for signs of inflammation, infection (redness, tenderness, drainage . and assess the arm for pain, warmth, swelling .). Using sterile technique . cleanse the area thoroughly with a chlorhexidine (antiseptic) . before redressing the site, use a sterile tape measure to measure the external length of the catheter from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, the facility failed to provide the necessary care and services to minimize the potential for the worsening of pressure ulcers for 1 of 4 sampled resident (Resident #98) with pressure ulcers. Failure to consistently implement dressings and pressure relief interventions on pressure ulcer may result in the worsening of Resident #98's current foot/heel pressure ulcer or the development of new pressure ulcers. Findings include: Review of Resident #98's medical record occurred on all days of survey. The quarterly Minimum Data Set, dated [DATE], identified Resident #98 at risk of pressure ulcers had one unhealed stage 3 pressure ulcer. A physician's order, dated 04/23/24, stated, Left heel derma saver boot or float on pillow at all times, every day and night shift for skin integrity. A physician's order, dated 04/25/24, stated, Left heel: Foam border pressure dressing (Mepilex, or equivalent) for prevention on every day shift, change 2 x/week [twice a week] and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 05/11/23. Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure residents received adequate supervision/assistance to prevent accidents for 2 of 20 sampled residents (Resident #30 and #40) observed during transfers. Failure to ensure proper use of a mechanical sit-to-stand lift and/or wheelchair placed Resident #30 and #40 at risk for possible accidents with/without injury. Findings include: Review of the facility policy titled Safe Resident Handling Equipment occurred on 05/02/24. This undated policy stated, . check resident care plan or [NAME] [certified nurse aide (CNA) instructions] prior to transfer for type and size of sling and amount of assistance required . position the harness around the upper body . arms outside the harness . adjust the foot pad as needed . EZ way seat strap if additional lower body support is needed . raises the resident slightly off the seated surface . slide the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, review of facility policy, and staff interview, the facility failed to provide safe and secure storage of medications for 1 of 8 medication/treatment carts (Unit 2) observed during medication pass. Failure to store all medications securely may result in unauthorized access to medications. Findings include: Review of the facility policy titled Medication: Administration Including Scheduling and Medication Aides occurred on 05/02/24. This policy, revised 03/29/24, stated, . 5. Medications will be stored in a locked medication cart . Observation on the morning of 04/30/24 showed a nurse (#7) left Unit 2's medication/treatment cart to deliver medications to residents down the hallway. The cart remained unlocked, unattended, and not within the nurse's view. During an interview on the morning of 05/01/24, an administrative nurse (#1) confirmed she expected the medication cart to be locked when not being accessed to dispense medications.

Based on record review, review of facility policy, and staff interview, the facility failed to follow professional standards of practice for 1 of 1 sampled resident (Resident #3). Failure to perform neurological checks following a head laceration/suspected head injury may result in delayed identification and treatment of the resident's medical condition. Findings include: Review of the facility policy titled Neurological Evaluation occurred on 09/27/23. This policy, dated 02/10/23, stated, . To establish a baseline neurological status upon which subsequent evaluations may be compared and changes in neurological status may be determined. Following a resident event that results in a known or suspected head injury . Initiate and document a baseline neurological evaluation . After the completion of initial neurological evaluation with vital signs, continue with evaluations every 30 minutes x [times] 4, then every eight hours x 3 days or as directed by the provider. Review of Resident #3's medical record occurred on 09/27/23. A progress note dated 09/24/23 at 2:02 a.m. identified, Late…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.17.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 3 of 27 sampled residents (Resident #18, #67, and #83) and one closed record (Resident #117). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: SECTION A: IDENTIFICATION INFORMATION The Long-Term Care Facility RAI Manual, revised October 2019, page A22-A23, states, . A1500: Preadmission Screening and Resident Review (PASRR) . Review the Level I PASRR form to determine whether a Level II PASRR was required. Review the PASRR report provided by the State if Level II screening was required. Code 0, no: . if any of the following apply: PASRR Level I screening did not result in a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility policy, and staff interview, the facility failed to review/revise comprehensive care plans to reflect the residents' current status for 6 of 27 sampled residents (Resident #34, #36, #54, #80, #116, and #172). Failure to review/revise the care plans to reflect residents' current status limited the staff's ability to communicate needs and ensure continuity of care for each resident. Findings include: Review of the facility policy titled Care Plan occurred on 05/11/23. This policy, reviewed/revised on 09/22/22, states, . Each resident will have an individualized, person-centered, comprehensive plan of care that will include measurable goals and timetables directed toward achieving and maintaining the resident's optimal medical, nursing, physical, functional, spiritual, emotional, psychosocial, and educational needs.This plan of care will be modified to reflect the care currently required/provided for the resident. It will address the relationship of items or services…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

1. Based on observations and staff interview, the facility failed to label and date food to ensure food quality in 1 of 1 kitchen and 1 of 2 kitchenettes (Unit 2). Failure to store food with labels and dates has the potential to affect quality of food served to residents, staff, and visitors. Findings include: A tour of the kitchen occurred on 05/08/23 at 11:30 a.m. with a dietary staff member (#7). Observation showed the following opened and undated items: * Lemon glazed bread and orange poppy bread * A box of gluten free taco shells * Bags of powdered sugar and brown sugar * A 25-pound container with rice Observation of the Unit 2 kitchenette occurred on 05/11/23 at 10:30 a.m. and showed the following opened and undated items: * Four different types of unidentifiable cereal in plastic containers * A bag of Raisin Bran * A bag of frozen gluten free bread * Plastic wrapped mozzarella and American cheese slices During an interview on 05/08/23 at 11:45 a.m., the dietary staff member (#7) confirmed the opened food items lacked labels and dates. 2. Based on observation, review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, review of facility policy, and staff interview, the facility failed to follow infection control practices for 5 of 5 sampled residents (Resident #25, #36, #57, #172, and #222). Failure to practice infection control during cares has the potential for transmission of communicable diseases and infections to residents and staff. Findings include: Review of the facility policy titled Hand Hygiene occurred on 05/11/23. This policy, dated 10/21/22 stated, . hand hygiene is the single most important factor in preventing the spread of disease-causing organisms to patients and personnel in healthcare settings . all employees are responsible for maintaining adequate hand hygiene by adhering to specific infection control practices . adhere to the 4 moments of hand hygiene and 2 zones of hand hygiene . entering a room . before clean task . after bodily fluid/glove removal . exiting a room . zones: patient zone and health care zone . Hand hygiene should be performed after glove removal . hand sanitizer . when entering patient room . when gloves used to perform procedure,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, review of facility policy, and staff interview, the facility failed to provide care in a manner and environment that maintained, enhanced, and respected the resident's dignity for 1 of 3 residents (Resident #102) observed during insulin administration. Failure to provide privacy in a manner/environment that maintained bodily privacy does not preserve the resident's right to privacy or enhance their quality of life. Findings include: Review of the facility's policy titled Resident Dignity occurred on 5/10/23. This policy, revised 10/26/22, stated, . maintain the dignity of all residents . care for the residents in a manner and in an environment that maintains or enhances each resident's dignity and respect . respecting resident's private space . Observations on 05/10/23 at 8:00 a.m. showed a nurse (#11) administer Resident #102's insulin in view of other residents and staff in the dining room and two adjacent hallways. The nurse after preparing the insulin pulled the resident's left shirt sleeve up and administered the dose then with the second insulin repeated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on information provided by the complainant, record review, and review of facility policy, the facility failed to immediately notify the family/power of attorney (POA) of a change in the resident's condition for 1 of 7 residents (Resident #105) with impaired skin integrity. Failure to promptly notify the family/POA of changes in skin integrity limited their ability to make informed decisions regarding medical care. Findings include: The complainant alleged the facility failed to notify the family/POA when a resident experienced a change in their condition. Review of the facility policy titled Notification of Change occurred on 05/11/23. This policy, reviewed/revised on 11/29/22, stated, . A facility must . consult with the resident's . representative(s) . when there is . a significant change in the resident's physical . status . a need to . commence a new form of treatment . Review of Resident #105's medical record occurred on all days of survey. Diagnoses included pressure ulcers to the right heel and coccyx. The current care plan identified . The resident has actual pressure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of Medicare Part A letters/notices and staff interview, the facility failed to ensure the completion of the Centers for Medicare/Medicaid Services (CMS) Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) form (CMS-10055) for 2 of 2 sampled residents (Resident #101 and #114) discharged from Medicare Part A services who remained in the facility. Failure to ensure the residents and/or resident representative received all available options for care and the option to appeal the termination of coverage has the potential to hinder the residents' right to an expedited review of a service termination. Findings include: Review of the Medicare Part A letters/notices for Residents #101 and #114 occurred the morning of 05/11/23. The review identified the facility provided the SNFABN form to Resident #101's resident representative on 02/14/23 and failed to obtain documentation of the resident's wishes for continued services and/or the option to appeal the termination of Medicare Part A coverage. The facility failed to provide the SNFABN form to Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, review of the North Dakota Provider Manual Preadmission Screening and Resident Review (PASARR) and Level of Care Screening Procedures for Long Term Care Services, and staff interview, the facility failed to complete a status change assessment for 1 of 6 sampled residents (Resident #36) reviewed for PASARR. Failure to complete a change in status assessment with a newly diagnosed mental illness may result in the delivery of care and services that are inconsistent with the resident's needs. Findings include: The North Dakota PASARR Provider Manual, revised December 2020, page 13, states, . Change in Status Process . Whenever the following events occur, nursing facility staff must contact [the contracted agency] to update the Level I screen for determination of whether a first time or updated Level II evaluation must be performed. These situations suggest that a significant change in status has occurred: . If an individual with MI, ID, and/or RC [mental illness, intellectual disability, and conditions related to intellectual disability referred to in regulatory…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, review of facility policy, and family and staff interviews, the facility failed to ensure residents received adequate supervision/assistance to prevent accidents for 1 of 7 sampled residents (Resident #116) who required a stand-lift for transfers. Failure to ensure proper use of a mechanical stand-lift placed all residents at risk for accident and/or injury. Findings include: Review of the facility policy titled Fall Prevention and Management occurred on 05/11/23. This policy, revised 03/29/23, stated, . Fall - refers to unintentionally coming to rest on the ground, floor or other lower level. Communicate that a fall has occurred during shift change and daily stand-up meetings . Complete the Falls Tool UDA [form] if not done in the post-fall huddle. Report to the state regulatory agency when appropriate. Review of Resident #116's medical record occurred on all days of survey. Diagnoses included osteoarthritis, pain, weakness, and a history of falls. The current care plan stated, . The resident has an ADL [activities of daily living] self care performance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on information provided by the complainant, observation, and record review, the facility failed to provide appropriate toileting assistance for 2 of 27 sampled residents (Resident #25 and #172) dependent on staff for toileting. Failure to provide incontinence care may result in a loss of dignity and place residents at risk for skin breakdown. Findings include: Information provided by the complainant indicated staff failed to toilet residents as scheduled. The complainant indicated he/she observed a resident sitting in his/her bed or wheelchair soaked in urine. The facility failed to provide a copy of their policy addressing toileting cares upon request. - Review of Resident #25's medical record occurred on all days of survey. The annual Minimum Data Set (MDS), dated [DATE], identified frequently incontinent of bladder and bowel and required total assistance from two or more staff members for toileting cares. The current care plan stated, . The resident has an ADL [activities of daily living] self care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide the necessary care and services for 1 of 4 sampled residents (Resident #101) receiving oxygen. Failure of staff to ensure a physician's order for oxygen flow rate and document an oxygen flow rate may complicate a resident's respiratory status. Findings include: Review of the facility policy titled Oxygen Administration, Safety, Mask Types occurred on 05/10/23. This policy, dated 06/29/22, stated, .Turn gauge to start flow rate at prescribed liters per minute (per physician's orders) . Document as appropriate . Observation on all days of survey showed Resident #101 with continuous oxygen administered at two liters per nasal cannula. Review of Resident #101's medical record occurred on all days of survey and included diagnoses of chronic obstructive pulmonary disease and congestive heart failure. A provider order, dated 03/21/23, indicated, . 02 [oxygen] via nasal cannula to keep sats [saturation] > [greater than] 89. Review of oxygen saturation documentation from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility policy, and staff interview, the facility failed to ensure 2 of 2 sampled residents (Resident #80 and #172) with a history of trauma and/or diagnosed with post-traumatic stress disorder (PTSD) received appropriate treatment and services to meet their assessed needs. Failure to provide appropriate person-centered and individualized treatment and services may result in resident's inability to attain their highest practicable mental and psychosocial wellbeing. Findings include: Review of the facility policy titled Trauma Informed Care occurred on 05/11/23. This policy, reviewed/revised on 10/26/22, stated, . individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has a lasting adverse effect on the individual's functioning and mental, physical, social, emotional, or spiritual well-being. Trauma occurs when a resident's coping mechanisms are…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.